I never had a bladder instillation when I suffered from ‘interstitial cystitis’ – my doctor at the time couldn’t even diagnose me, so I didn’t get to try any conventional treatment for IC. In my desperation, I very quickly turned to natural interventions… and the rest is history.
We often speak of orthodox medicine as being ‘evidence based’ and anything ‘alternative’ as being ‘quackery’. I have long come to understand that a lot of ‘alternative’ interventions are in fact very much following the newest evidence but also that ‘quackery’ (and maybe more importantly ego) can be found in all walks of medicine.
So far, I’ve mostly stayed away from writing about conventional treatments and it’s not my intention to slag anything off. But after hearing from so many sufferers I’ve spoken to that instillations have not helped them, I wanted to see if their use is actually evidence-based.
Now I don’t have the training or experience to come to such conclusions, but luckily I don’t need to -thanks to Cochrane Systematic Reviews.
What is a Cochrane Systematic Review?
‘A Cochrane Review is a systematic review of research in health care and health policy that is published in the Cochrane Database of Systematic Reviews’ [according to Cochrane]. A systematic review is a review of all the literature on a specific research question. Only papers that pass certain eligibility criteria (for quality) are then included in the final review, which can already tell us how much of the research that has been done is actually relevant.
Cochrane itself is an independent collaboration of scientists from all walks of life, many of them volunteers, that seeks to ‘promote evidence-informed health decision-making’ [About Cochrane].
They have conducted a systematic review of all clinical studies using bladder instillations on adults diagnosed with IC/Painful Bladder Syndrome. At the time of the review, 61 papers existed, of which only 9 met their quality criteria. This equaled 616 participants, mainly women.
What is a Bladder Instillation?
A bladder instillation is basically putting medication directly into the bladder via a small catheter, rather than taking it orally.
According to the NHS, it is ‘a combination drug therapy to help painful bladder or cystitis type symptoms including frequency, urgency, burning pain or stinging sensations when passing urine. It works by reducing inflammation and discomfort within the bladder.’
Different medications are used for this purpose (there may be others):
- Lidocaine – local anaesthetic used to numb tissue in specific area
- Bi-carbonate – used to alkalize urine (to reduce burning)
- Heparin and hyaluronic acid, chondroitin sulphate – temporarily ‘repairs’ the protective GAG-layer of the bladder wall
- Dimethyl sulfoxide (DMSO) – thought to reduce bladder irritation, relax bladder muscle, increase bladder capacity and have pain-relieving action on bladder nerves
- Resiniferatoxin and Capsaicin – desensitization of nerves in the bladder to reduce pain and urgency
- Bacillus Calmette-Guerin (BCG) – immunotherapy based on the belief that IC is autoimmune in nature
- Pentosanpolysulphate – reduction of the permeability of bladder wall so toxins from the urine can’t get to nerves
- Oxybutin – reduction of bladder spasms
- Clorpactin (oxychlorosene) – antimicrobial
- Silver nitrate – antiseptic and astringent
- Steroids – anti-inflammatory
Are Bladder Instillations Evidence-Based?
As you can see from above, bladder instillations aren’t one treatment – it’s merely a form of delivery of different drugs.
Therefore it’s probably not a simple ‘yes’ or ‘no’ answer.
But let’s see what the researchers at Cochrane found out:
Overall, the researchers found that the number of trials that met their quality requirements was limited and there weren’t high-quality trials on all the different medications used for bladder instillations.
The researchers stated that ‘the lack of good evidence for some [instillation treatments] that are more commonly used was notable’.
Let this sink in.
Further, there was no standardized method of treatment and therefore the researchers found it difficult to compare or combine results and, as you can see from the small number of papers that made it into the review, most of the studies were poorly designed.
And even the studies that made it into the review were rather small.
With regards to the individual instillation treatments, here is what they found:
- Resiniferatoxin: there was no sustained difference in symptoms after treatment and pain during treatment was reported 50% more often compared to other instillation treatments.
- Dimethyl sulfoxide (DMSO): no apparent difference in symptoms compared to a placebo was shown.
- Bacillus Calmette-Guerin (BCG): a small improvement in pain and a general symptom improvement was found for this treatment.
- Pentosanpolysulphate: there was some evidence for increased bladder capacity on this treatment but not much else.
- Oxybutin: there was some evidence for improved bladder capacity and reduced frequency on this treatment but it wasn’t evaluated for pain.
- Alkalizing agents (e.g. Bi-carbonate): no clear differences in symptoms were found for this treatment.
The researchers concluded that BCG and Oxybutin are the most promising treatments but that there is a clear need for further high-quality trials.
They stated that ‘Evidence about current treatments is insufficient; some currently used agents have significant adverse effects; and instillation itself is associated with adverse events.’
So with this in mind, let me give you the definition of evidence-based medicine:
‘Evidence-based medicine is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research […]requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations’ [Wikipedia]
What are your thoughts: is the use of bladder instillations evidence-based? What is your experience with bladder-instillations? Let me know in the comments!
Pin it for later:
Dawson, T. and Jamison, J. Intravesical treatments for painful bladder syndrome/ interstitial cystitis Cochrane Database of Systematic Reviews Version published: 17 October 2007 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006113.pub2/full?highlightAbstract=cystiti&highlightAbstract=interstiti&highlightAbstract=cystitis&highlightAbstract=interstitial
NHS Patient Information Factsheet Bladder Instillation http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Womenshealth/Bladder-instillation-patient-information.pdf
Bladder Health UK Intravesical Medications accessed Nov 2018 http://bladderhealthuk.org/bladder-conditions/interstitial-cystitispainful-bladder-syndrome/icpbs-treatments/intravesical-medications
Cochrane Library About Cochrane accessed Nov 2018 https://www.cochranelibrary.com/about/about-cochrane
Wikipedia Lidocaine https://en.wikipedia.org/wiki/Lidocaine
Wikipedia Evidence Based Medicine https://en.wikipedia.org/wiki/Evidence-based_medicine